Adolescent Depression Assessment & Evaluation Form

Pediatric Depression Self-Assessment Questionnaire

Depression in children can look like many things: indifference, laziness, stubbornness, hostility, and outright rebelliousness. However, beneath this outward appearance many children with depression experience profound sadness, loss of joy in life, and lack of sense of purpose in their future. As a result of their depression, many children will experience problems in their relations with family and friends that lead to further isolation, academic decline, involvement in drugs and alcohol, and possibly delinquent behaviors. Fortunately, with early detection and treatment, these children can often go on to live satisfying, fulfilling lives, and reverse many of these problems.

We are currently conducting research in pediatric depression. Although your child will need to meet with our medical staff for a thorough evaluation prior to entering a study, your answers to this questionnaire are important. Please take a moment to answer the following questions:

Name of Person Completing this Questionnaire:

Relationship to Child/Adolescent interested in study:

Please enter your zip code:

Please note that a parent or guardian would be required to accompany the patient to each visit.

Name of child or adolescent interested in study (optional):

Age of child or adolescent interested in study:

Page 2 of 4 >>

Symptoms

We’d like to know what symptoms of depression your child is suffering with. Please check any that you have observed on the list below. In the comment space, you may list additional symptoms or information that you’d like us to have.

Feeling bad about himself or herself

Feeling sad or down

Having crying spells

Having difficulties at school

Withdrawing from friends or family

Feelings of discouragement or failure

Frequent stomach ache or headache

Trouble completing everyday duties and chores

Irritability

Loss of interest in things previously enjoyed

<< Page 1 of 4 | Page 3 of 4 >>

Questions or Comments?

Please feel free to use the space below to list additional symptoms, ask questions or tell us more about yourself or about the potential participant.

<< Page 2 of 4 | Page 4 of 4 >>

Your Contact Information

We’d like to give you a call and further discuss our pediatric depression research program. Please provide your best contact information below:

Phone 1:
Phone 2:
Best time to reach you:
May we leave messages at both of the numbers above?	Yes No
E-mail:
Image Verification:

<< Page 3 of 4 | Submit Your Responses >>